MIDLAND HEALTH and
   SENIOR SERVICES

APPLICATION REQUESTING A HEALTH INSPECTION OF A DAY CARE FACILITY

PRINT OR TYPE ALL INFORMATION

Name of Facility:________________________________________________________________

Location of Facility:______________________________________________________________

Owner of Facility:________________________________________________________________

Mailing Address:__________________________________________ Telephone:_____________
                          STREET/PO BOX                            CITY/STATE/ZIP                

An application must be submitted before a health inspection will be made.

The applicant hereby acknowledges an understanding of the provisions of the Ordinance relative to the payment of  the $20.00 inspection fee.

Comments:

MIDLAND HEALTH DEPARTMENT
P.O. BOX 4905
MIDLAND, TEXAS 79704

Received By:___________________________________ Date:____________________________